Bluegrass Community & Technical-Lexington-TS-Permission Form

Educational Talent Search

Permission and Insurance Form
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Part 1 ~ Student Participant Information
Student Name*

First NameMiddle NameLast Name
Email (Not school one)*
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
School
Preferred Name
Additional Emergency Contact Information

In the event of an emergency, and the parent/guardian cannot be reached, please indicate another emergency contact.
Name:

First NameLast Name
Relationship to Student:
Phone:
(999)999-9999

Part II ~ Medical Insurance Information
Age
Date of Birth

MonthDayYear
mm-dd-yyyy
Guardian 1:
Name:

First NameLast Name
Relation to student:
Work Phone:
(999)999-9999
Cell Phone:
(999)999-9999
Guardian 2:
Name:

First NameLast Name
Relation to student:
Work Phone:
(999)999-9999
Cell Phone:
(999)999-9999
Parent's Insurance Covering Participant

(primary insurance information)
Policy Holder Name
Policy Holder DOB

MonthDayYear
mm-dd-yyyy
Policy Number
Member ID #
Insurance Company
Upload health cards here

Cancelof
No Coverage (check box if no health insurance)

There is no health insurance coverage for this participant at this time

Part III ~ KCTCS Excess Insurance for Camps/Conferences/Field Trips ~ Summary of Coverage
Insurance Carrier

Reisert & Associates (United States Fire Insurance Company)

Coverage

Insurance coverage is on an excess basis only. The participants' personal health insurance policy will be primary and provide coverage for accident. The excess policy will cover any out of-pocket expense not paid by the participants' personal insurance up to the limits of the policy listed below. (This includes payment of the deductible and coinsurance amounts if applied under the participants' personal policy.) The beneft period is 52 weeks from the date of an injury. The first expense must be incurred within 180 days of the accident and care is medically necessary. If the participant does not have personal health insurance coverage, this excess policy will pay first dollar, up to the limits of this policy. Pre-existing conditions are not covered. A pre-existing condition is any condition for which a prudent person should have sought treatment or was treated in the previous six months.

Coverage Benefits & Limits

Accident Medical Expense (Excess): $25,000; Accident Dental Expense (Excess): URC; Physical Therapy: URC; Deductible: None;AD&D and Paralysis, Principle Sum: $15,000

*URC - Usual, Reasonable & Customary

Part IV ~ Consent to Medical Treatment/Insurance Statement
It is understood that authority is given to the Kentucky Community and Technical College System, or anyone they may designate, to have my son/ daughter treated for injuries they incur during a designated camp, conference, or field trip activity with the college.

I understand that l will be notified if a health problem arises, but in the event/ cannot be reached by telephone, hereby give KCTCS, or anyone they may designate, permission to seek medical treatment for the participant named below, including surgery (on an emergency basis) or additional advanced treatments (MRI, lab tests, etc.) as deemed necessary by competent medical personnel.

I am aware that, as the adult participant, or as the parent or legal guardian of the participant named below, I wll be responsible for any expenses incurred outside of the limits provided by the Kentucky Community and Technical College System's Camps/Conference/Field Trip Policy. I also understand that the System insurance coverage is on an "excess" basis only. The excess policy will cover any out-of-pocket expense not paid by the participant's personal insurance up to the limits of the policy listed above.

Part V ~ Authorizations to Obtain and Utilize Images
lt is the policy of Bluegrass Community and Technical College Educational Talent Search that informed written consent be granted for all photography and/ or videotaping. By signing below, the parent/guardian of the student applicant hereby grants permissian to ETS to photograph and/or videotape either the adutt parent/guardian or the minor child upon admission into ETS. The parent/ guardian also authorizes Bluegrass Community and Technicat College Educational Talent Search to use and/or permit others to use the aforementioned images in educational, informational and promotional activities for ETS without compensation

Part VII ~ Signatures
We have both read, understood, and agree to the above statements, and certify that, to the best of our knowledge, all information provided herein Is correct. The student has the parent's permission to participate in this ETS event:
Parent/ Guardian Signature

Clear
Date

MonthDayYear
mm-dd-yyyy
Student Signature

Clear
Date

MonthDayYear
mm-dd-yyyy

Student Health History and Parent/Guardian Consent Form TRIO Educational Talent Search Bluegrass Community & Technical College
Date of Birth

MonthDayYear
mm-dd-yyyy
Does the student know how to swim?

YesNo
Does the student have any physical or health limitations and/or disabilities (whether temporary or permanent) that would limit safe participation in the TRIO Educational Talent Search activities?

YesNo
If yes, please indicate:
Does the student have any chronic or recurring injuries?

YesNo
Has the student had a kidney or other transplant?

YesNo
Is the student pregnant?

YesNo
Health Checklist: Please check the following physical disabilities or conditions that may limit the student's participation:

Hearing or vision problemsRespiratory problemsBack problemsJoint problemsRecent serious illnessRecent surgeryRecent hospitalizationSerious reaction to high or low temperaturesFrequent muscle crampsHigh or low blood sugarSeizuresHeart problemsAsthmaOther (specify below)

Allergies: Indicate any allergies, student's reaction, and treatment:

	Allergy	Reaction	Treatment
1
2
3
4
5

Medications: Please indicate all medications student is currently taking, the condition for which medication is needed, and if that medication will be needed during TRIO ETS activities. If so, make sure student has medication with them.

Medications

	Medication	Condition	Needed during program actitives?
1
2
3
4
5

The student may keep their personal medications during TRIO Educational Talent Search activities. However, TRIO ETS staff will not give any medication to the student without your verbal and/or written permission. The student is also not permitted to give medication to another student.
Please indicate which of the following you give permission to Talent Search Staff to administer to the. student as needed:

AspirinAdvil (ibuprofen)Pepto BismolTumsImodiumBenadrylTylenol (acetaminophen)Other: Please explain
Dietary allergies or restrictions:
I hereby give permission for {main_name} to particípate in the TRIO Educational Talent Search events and activities during the 2023-2024 year beginning September 1, and ending August 31, 2024.

In case of an emergency/injury, I grant permission for {main_name} to receive medical attention deemed necessary by staff and/or qualified medical personnel during the entire time s/he (listed within) is participating in the TRIO Educational Talent Search Program at Bluegrass Community & Technical College

PARENT/GUARDIAN: Every reasonable precaution will be taken to provide safety and care for the student. Every effort will be made to notify you in the event of an accident or injury, which may require emergency care. If you cannot be contacted, permission is granted to the staff to seek medical attention. All financial responsibility for medical care and/or hospitalization provided in ‣ the case of an emergency is to be assumed by the parent/guardian.
Signature of Student

Clear
Date

MonthDayYear
mm-dd-yyyy
Name of Parent/Guardian

First NameLast Name
Signature of Parent/Guardian (if student is under the age of 18)

Clear
Date

MonthDayYear
mm-dd-yyyy

Rules & Expectations
1. All students must respect the property of others, including but not limited to that of TRIO Educational Talent Search, the host college/university, Bluegrass Community and Technical College, hotels and properties visited, as well as all other participants and staff.
2. Students are required to participate in all scheduled activities unless prior arrangements are made by an Educational Advisor or Program Director.
3. Boundaries- Students are not to go beyond the established boundaries without being accompanied by a staff member, parent/guardian, or other designated adult.
4. Public displays of affection or related inappropriate acts are not permitted. Failure to comply will result in disciplinary action up to and including dismissal from the program.
5. Students, regardless of gender, who are in a relationship with one another, are prohibited from sharing a room in the residence halls or hotels.
6. Students may not enter one another's rooms in residence halls or hotels for any reason other than an emergency.
7. Incense and candles are prohibited from use in residence halls, campus facilities, hotels, etc. Do not bring these items with you to campus or on a trip.
8. Students must be fully dressed, including shoes and not pajamas, in all public areas of the residence halls and hotels, etc. Clothing with profanity or other inappropriate designs and logos are not permitted. Tennis shoes and/or comfortable shoes are highly recommended.
9. No "horseplay"/play fighting or use of profanity. Violation may result in program dismissal.
10. Possession of alcoholic beverages, unlawful drugs or paraphernalia, misuse of prescription medicines, smoking, or use of tobacco of any kind, including vaping of any kind, are prohibited at all TRIO Educational Talent Search activities /events and trips. Violation of this rule will result in dismissal from the program.
11. Cell phones and earbuds/headphones may NOT be used during classes, presentations, while touring campuses or walking outside, unless in case of an emergency. This is primarily a safety rule but also speaks to respect of other's time, and it must be adhered to at all times. Mindful usage is permitted on buses. Failure to comply may result in program dismissal.
12. If permitted to leave the residence hall or specified area, students must sign out stating their exact location. This is to ensure student's safety and to guarantee they may be reached in case of an emergency.
13. Students who are not attending TRIO ETS in-school workshops and/or out of school time events/activities will not be permitted to attend field trips.
14. Students with failing grades will not be permitted to participate in field trips or events until the grade is satisfactory.
15. Students with excessive absences or behavioral issues at school will not be permitted to participate in field trips or events until improvements are demonstrated.
16. Due to the short nature of our schedule programs and events, visitation is not permitted at any time. If items are forgotten, a parent/guardian must make arrangements with a staff member to obtain the items for the student.
17. Parents/guardians understand they are to provide transportation to and from events/activities in a timely manner. Students will be advised to reach out at least 30 minutes before arrival from a field trip. Chaperones are not required to wait beyond 30 minutes upon arrival.
18. NO SHOW: If you confirm your attendance for any trip and do not attend without properly notifying the program, you may not be permitted to attend the next field trip(s). A minimum of 24 hours' notice is required to ensure we can offer your spot to another person from the waitlist.
19. Students are prohibited from renting or using mobility Items such as bicycles, scooters, Segways, etc. while on campus or traveling with ETS to any locations.
20. Students should eat with the group for all meals unless otherwise approved by a staff member. Students are NOT permitted to order Door Dash/Uber Eats, etc. unless pre- approved by a staff member.
NOTE: Disregard* for any of the aforementioned rules as well as any instated after arrival, may result in program dismissal and/or parent/guardian pick up regardless of time or location.

*Should violations occur, students will be prohibited from field trips, especially overnight trips, for at least one year or until further notice at the discretion of the ETS Staff.

Rules & Expectations
I have received a copy of, reviewed, and understand the TRIO Educational Talent Search Rules and Expectations. I understand that I must adhere to these rules and guidelines or be dismissed from the program and a parent/guardian must pick me up at that time regardless of time or location.
Student Name

First NameLast Name
Student Signature

Clear
Date

MonthDayYear
mm-dd-yyyy
Parent/Guardian Name

First NameLast Name
Parent/Guardian Signature

Clear
Date

MonthDayYear
mm-dd-yyyy
*** This form is valid from the date signed to September 1st of that year.***
WAIVER AND RELEASE OF ALL LIABILITY

AND AGREEMENT TO INDENMIFY AND HOLD HARMLESS

In order to participate in this upcoming trip. (hereinafter, the “EVENT”), you must sign and date this form. If you are a minor under the age of eighteen and you wish to participate in this event, your parent and/or legal guardian must sign this waiver before you will be permitted to participate.
I, ______________________________, (participant’s name)
hereby waive, release and forever discharge KCTCS, its officers, directors, agents, organizers, staff, and volunteers (hereinafter “ORGANIZATION”) from any and all liability for and hold Organization harmless against any and all claims, suits, damages, fines, penalties, liabilities, and expenses resulting from any personal injuries or property damage that I may sustain as a result of, or during, my participation in EVENT, including any personal injuries or property damage that may be sustained as a result of the negligence, in whole or in part, of the ORGANIZATION. I further agree to indemnify the ORGANIZATION, its officers, directors, agents, organizers, staff and volunteers from any and all claims of any nature whatsoever, including, but not limited to, personal injury and property damage, by any third party or third parties, which they claim are caused, in whole or in part, as a result of any act(s) or conduct, whether unintentional, negligent, or intentional, which may occur immediately prior to, during, or immediately following the EVENT.

I understand that I assume responsibility and liability for any personal property I bring to the EVENT and agree to indemnify and hold harmless the ORGANIZATION, its officers, directors, agents, organizers, volunteers and staff from any claims arising out of, in whole or in part, the use in any way of my property and that may occur immediately prior to, during, or immediately following the EVENT.

By executing this waiver, release, agreement to indemnify and hold harmless, I acknowledge that I understand and agree to accept each of the statements, waivers, releases and agreements contained in this document and by affixing my signature hereto affirm that I will abide by these policies.
PARTICIPANT/GUARDIAN SIGNATURE

Clear
DATE SIGNED

MonthDayYear
Date
EMERGENCY CONTACT NAME

First NameLast Name
PHONE NUMBER
(999)999-9999

Educational Talent Search

Parent's Insurance Covering Participant